Fractures of the Talar Head: A Series of 16 Patients

Category: Hindfoot; Trauma Introduction/Purpose: Fractures of the talar head are very rare accounting for just 5-10% of talus fractures and fewer than 1% of all fractures. As such, limited clinical literature is available to guide management of these injuries. We present the largest clinical series on talar head fractures to date. Methods: We performed a retrospective review of all patients presenting to three level-1 trauma centers with major fractures of the talus (fractures of the neck, body or head) over a 14-year period. From this cohort of patients, we identified patients presenting with fractures of the talar head with available computed-tomographic (CT) imaging of the foot allow proper fracture evaluation and characterization. In total, 258 patients with major fractures of the talus were identified. Sixteen patients (6.2%) with talar head fractures met inclusion criteria. Results: Most injuries were due to falls from height and only 4 were isolated. The navicular was fractured in 7 patients (43.8%). Six patients (37.5%) exhibited comminuted fracture patterns, while the remaining demonstrated simpler shear or impaction injuries. Four patients underwent fixation of the talar head, 3 were treated with primary stabilization or fusion of the talonavicular joint, and two patients were treated with head fragment excision. The talar head was managed in a closed fashion in the remaining seven patients, five of which presented with comminuted fracture patterns. Eight patients showed radiographic evidence of post- traumatic arthritis (PTA) at mean follow-up of 15.5 months. In all instances of PTA, the patient had sustained a comminuted talar fracture, an associated navicular fracture or both. Conclusion: Talar head fractures are extremely rare injuries with sparse literature to guide clinical management. Simple shearing or impaction fractures may be amenable to surgical fixation with favorable radiographic outcomes. Comminuted fractures and/or concomitant navicular trauma at the time of injury may be associated with increased incidence of talonavicular arthrosis.

Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures

Background Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. Methods The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. Results The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). Conclusions The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients’ prognosis than the conventional Neer classification.

Malunion of the Acetabulum Treated by Intra-articular Buttress

Acetabulum malunions are extremely difficult to treat, and for many years, surgical indications have been dominated by total hip replacement. We treated a protruding acetabular malunion, 20 years ago, using an intra-articular buttress, by means of an allograft corresponding to a femoral head fragment which had been cryopreserved. The radiological and clinical result with this extended follow-up is quite remarkable, which has motivated us to present this original technique.

SEKHMET STATUES FROM THE REIGN OF AMENHOTEP iii IN THE BRITISH MUSEUM and A FORMERLY UNCATALOGUED HEAD FRAGMENT: A REASSESSMENT

Beyond the borders of Egypt, the British Museum has the largest collection of granodiorite statues and fragments of statues of the goddess Sekhmet produced in the reign of Amenhotep iii (c 1390–1352 bc; eighteenth dynasty). With so much new material being uncovered in recent years at the site of Amenhotep iii’s funerary temple at Kom el-Hettan in Luxor (Egypt), a reassessment of the British Museum statues was inevitable. The British Museum statues are an ideal sample group for study, offering variations in type, proportions, stone colouration, decoration and state of finish. The group also includes a formerly uncatalogued head fragment with an unusual uraei crown, which relates to surviving examples found at the Mut Temple at Karnak and at Kom el-Hettan in Luxor.

Sculptures and “the sanctuary of Aesculapius” in Mediana

During the excavation in 2002, in trench 24A in Mediana, a head fragment of a sculpture was discovered, belonging to a life-sized, or possibly slightly larger, sculpture. Analysis of this head indicates that it is of Aesculapius. According to its stylistic features, it can be dated into the very end of the 2nd and the early 3rd century. This find raised the question as to whether there could have been a sanctuary dedicated to Aesculapius or Hygieia in Mediana. In this paper, statuettes of these two deities have been reconsidered, all of them unearthed within the ?villa with peristyle?. New dating has been suggested and it was concluded that the audience hall (triclinium), being the largest room within the villa, was turned into a sanctuary. Its apsis was turned into the most sacred place, separated from the rest of the hall with a bronze railing. The rest of the villa could have been used for the reception of the sick, just as in any other Asclepaion. At the same time, questions regarding other sculptures discovered within the villa were posed. The appearance of mythological sculptures in other villas throughout the Roman Empire was analysed in detail and it was concluded that the sculptures in Mediana were exclusively regarded as villa decoration and not as part of any cult. All of them were brought here from different places and they are dated differently. One should not discard the possibility that, for a short period of time, some of them, especially those representing deities with possible healing features, were in a sanctuary of Aesculapius. The sanctuary could have been opened during the reign of Julian the Apostate and it operated until his death.

Four-part proximal humeral fractures: diagnosis with the ‘sunset’ sign on anteroposterior radiograph

INTRODUCTION Four-part proximal humeral fractures require surgical intervention. However, they can be difficult to diagnose in radiological images. We aim to define a new, easily recognisable, radiological sign as a predictor of four-part fracture of the proximal humerus in a plain anteroposterior radiograph of the shoulder. PATIENTS AND METHODS We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proven otherwise. Between 2002 and 2006, 80 consecutive patients had surgical treatment of their proximal humeral fractures in our unit. Pre-operative radiographs and operative notes of 79 patients were evaluated independently by three blinded observers. The presence of ‘sunset’ sign was recorded. Findings were then correlated with the operative diagnoses to confirm whether they were four-part fractures or not. With 95% confidence interval, we calculated the sensitivity, specificity, positive and negative predictive values for our diagnostic sign. RESULTS Of 79 patients, 30 displayed ‘sunset’ sign in their pre-operative radiograph. Of these, 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign was 93%. The specificity and sensitivity were 95% and 78%, respectively. The sensitivity was affected by eight patients with four-part fractures with displaced articular head fragment which had dropped either medially or posteriorly. CONCLUSIONS These results suggest that, in patients with proximal humeral fractures, the presence of ‘sunset’ sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.

A study of low power laser on the regenerative process of Girardia tigrina (Girard,1850) (Turbellaria; Tricladida; Dugesiidae)

The mechanism of regeneration does not start to restore the wound until its corresponding epimorphic phase. A bioestimulation of tissues and cells by laser radiation depends on the wavelength, on the dose, and on the intensity of the light. The goal of this work was to verify the effect of the low power laser at 660 nm on the regenerative process of Girardia tigrina. The specimens were maintained in the laboratory under a temperature ranging from 19° up to 24 °C for 21 days. The planarians were anesthetized by placing them on ice and then cut them with a scalpel. The three treatments were as following: animals individually irradiated with 14 sessions with 1 minute duration (treatment 1), 14 sessions with 3 minutes duration (treatment 2), and without irradiation (control). The planarians were amputated and divided in three study treatments: a control group (without radiation), and two other treatments: irradiated for 1 minute, and irradiated for 3 minutes. The animals were irradiated with diode laser (660 nm) with 3.3 ± 0.3 mW of power, using 0.94 mW.mm-2 power density for each irradiation procedure. During the experiment, 14 irradiation sessions were undertaken. The specimens were fixed in Bouin, and stained with hematoxyline and eosin. From observation and histological analysis, it was possible to assess the effects of interaction between laser and tissue. The head fragment after 1 minute of irradiation presented a better organized tissue scheme, when compared with the other treatments. Aspects of the body fragments submitted to 3 minutes of light treatment were very similar to fragments that had not been injured. It can be concluded that there are changes in the quality of regeneration when treated with low power laser under the conditions mentioned above.